Reproductive concerns and its correlation with fear of recurrence and level of family support in patients of childbearing age with gynecologic malignancies

Background To discuss the current status of reproductive concerns and its correlation with fear of recurrence and level of family support in patients of childbearing age with gynecologic malignancies. Methods A convenient sampling method was used to enroll 188 patients with gynecologic malignancies in Nanjing Maternity and Child Health Care Hospital, Nanjing Drum Tower Hospital, General Hospital of Ningxia Medical University, and Haian Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine from September 2022 to April 2023. Patients were assessed using general information questionnaire, Reproductive Concerns After Cancer Scale (RCAC), Fear of Cancer Recurrence Inventory (FCRI) questionnaire, and Perceived Social Support-Family (PSS-FA) Scale. Results Among patients of childbearing age with gynecologic malignancies, the total RCAC score was (54.35 ± 7.52), indicating a moderate level of reproductive concerns. Patients scored (20.98 ± 4.51) on FCRI, implying a moderate level of fear of recurrence. The PSS-FA score was (9.57 ± 2.76), denoting a moderate level of family support. The total score and each dimensional score of RCAC were positively correlated with FCRI total score (P < 0.05), and negatively correlated with PSS-FA total score (P < 0.05). Fear of recurrence, family support level, number of children, educational background, treatment modality, and fertility intention were influencing factors for reproductive concerns in patients of childbearing age with gynecologic malignancies (all P < 0.05). Conclusion The reproductive concerns, fear of recurrence and family support are all at moderate levels in patients of childbearing age with gynecologic malignancies, and reproductive concerns are positively correlated with fear of recurrence and negatively correlated with family support.


Background
There were approximately 19.3 million new cancer cases and 2.3 million cancer deaths worldwide in 2020 [1].The incidence rate of malignant tumors in women of childbearing age is 1-2% and is rising year by year, with a younger trend [2].The continuous progress of malignant tumor prevention, diagnosis, and treatment technology, has greatly improved the 5-year survival rate of patients of childbearing age with gynecological malignant tumors.Gynecological cancers including cervical, ovarian, uterine and vaginal and vulvar cancer represent around 1 in 5 of all cancers diagnosed in women [3].The course of disease treatment may directly or indirectly affect the ovaries and uterus, leading to premature ovarian failure and amenorrhea, and other symptoms that adversely affect fertility [4].With the opening of the "two child" and "three child" policies in china [5,6], giving birth remains desirable among patients of childbearing age with gynecological malignancies who have not given birth at the time of diagnosis.Fertility anxiety refers to concerns about children's upbringing and fertility after an individual suffers from cancer.In some cases, it may pressure patients more than the disease itself, often lasting for several years, or even throughout the entire reproductive period [7,8].Fertility anxiety is a common problem among female patients with cancer, especially patients with gynecological malignant tumors.At present, research on the reproductive concerns of patients with gynecological malignant tumors is still in its infancy in China.This article investigates and analyzes the reproductive concerns, fear of recurrence, and family support levels of patients of childbearing age with gynecological malignant tumors, in order to identify important influencing factors of reproductive concerns.The aim is to attract the attention of domestic and foreign scholars and medical staff on the reproductive concerns of patients of childbearing age with gynecological malignant tumors and provide a reference for the development of scientific intervention measures in clinical practice.

General information
The convenient sampling method was used to select 188 patients diagnosed with gynecological malignant tumors from September 2022 to  6) automatic withdrawal during the study period.Through the sample size estimation method [9].The number of samples was calculated with power analysis [10,11].This study estimated 13 independent variables.The sample size is 10 times the number of independent variables and the sample was calculated in 0.15 effect sizes, 80% theoretical power, and 95% trust level.So the number of samples was determined as 188.All samples were reached.This study has been reviewed and approved by the Ethics Committee of the Maternity Hospital Affiliated to Nanjing Medical University (Nanjing Maternity and Child Health Hospital).The ethics acceptance number is 2022KY-135-02.

Survey tools
(1) General The scale was developed by Procidano et al. [16] and consists of 15 items.The answer to "yes" for each item is 1 point, "no" is 0 point, and the total score is 0-15 points.A higher score indicates a higher level of family support, with 0-5 indicating a low level, 6-10 indicating a medium level, and 11-15 indicating a high level.The scale has been validated for reliability and validity, and the overall Cronbach's α coefficient is 0.831.

Data collection methods
All data were collected by online questionnaires.An investigation team was established, with all team members receiving unified and systematic training.Investigation was conducted after obtaining the consent of the hospital, department, and patients.The research purpose, significance, and filling methods were explained to patients and families.After the patient agreed to participate, the QR code was scanned to fill out the questionnaire.The patient was informed that the survey is conducted anonymously, and all questionnaires need to be filled out independently by the patient.If the survey was inconvenient for the patient to complete, the nurse would fill in for him after asking.The site and stage of the tumor was filled out by the nurse.If there were any questions during the filling process, the investigator provided unified answers and submitted the completed information.A total of 200 questionnaires were distributed, 12 invalid questionnaires were excluded, and 188 were recovered.The effective recovery rate of the questionnaire was 94%.

Quality control
Relevant literature materials to the keywords "reproductive age", "gynecological malignant tumors", "reproductive anxiety", "fear of recurrence", "family support" were searched through channels such as "CNKI", "Wanfang", and "Pubmed".Experts from the educational institution were invited to randomly select 10 patients for pretesting to prepare for the investigation and conduct tests to ensure the reliability, validity, and applicability of the scales used in this study.All questionnaires and the data sorting process of the scale were operated by two people, including data collection, inspection, verification, entry, etc., and 10% of the questionnaires were selected for recheck by a third person to ensure data integrity, consistency, and reduce the bias of results.

Statistical methods
Data analysis was conducted using statistical software SPSS24.0, with counting data represented by "%".Comparisons were performed by χ 2 -test, measurement data is presented as (x ± s), a t-test was performed, and one-way ANOVA was performed for multiple group comparisons.
Pearson was used for correlation analysis, and multiple linear regression analysis was used for influencing factors.P < 0.05 indicates a statistically significant difference.

Current status of reproductive anxiety, fear of recurrence and family support scores
The  1.

Correlation between reproductive anxiety, fear of recurrence and family support
The Pearson correlation analysis results showed that the total score of reproductive anxiety and various dimension scores were positively correlated with the total score of relapse fear (P < 0.05), and negatively correlated with the total score of family support (P < 0.05), as shown in Table 2.

Single factor analysis of reproductive anxiety
The results of univariate analysis showed that there was a statistically significant difference in the scores of reproductive anxiety among patients of childbearing age with gynecological malignancies who had different numbers of  3.

Multiple regression analysis of reproductive anxiety
The level of reproductive anxiety in patients of childbearing age with gynecological malignant tumors was used as the dependent variable.The variables of recurrence fear and family support in correlation analysis and meaningful children's number, education level, treatment method, and fertility intention in univariate analysis were used as independent variables.The variable assignments are shown in Table 4.The results of multiple linear regression analysis showed that fear of recurrence, family support, number of children, educational level, treatment methods, and fertility intention were all influencing factors for fertility anxiety in patients of childbearing age with gynecological malignancies (P < 0.05), as shown in Table 5.

Analysis of the current status of reproductive anxiety, fear of recurrence and family support
The results of this study show that the total score of fertility anxiety (54.35 ± 7.52) of patients of childbearing age with gynecological malignancies is at a medium level, which is higher than that of patients at childbearing age with breast cancer (49.05 ± 15.64) in the study by Hailing et al. [17], and lower than that of patients with cervical cancer in the study by Wang et al. [18], indicating that differences in fertility anxiety level may be dependent on the subjects selected.Most studies show that [19,20], fertility concerns of patients with gynecological malignancies such as cervical cancer and ovarian cancer are at a high level, mainly due to possible hysterectomy and ovary removal during treatment, which will directly affect fertility.At the same time, influenced by the traditional concept of "inheriting the family line" in China, it is believed that women bear the responsibility of pregnancy, childbirth, and other responsibilities.Thus, women are more prone to reproductive concerns after suffering from gynecological malignancies and have high levels of reproductive concerns [21].However, most of the patients in this study have children, with 31 cases having no children, accounting for only 16.49%.Under the current high cost of childbirth and social pressure, those with children have lower willingness to give birth compared to those without children, resulting in a relatively low overall anxiety in the middle to lower levels.Additionally, we found that among all dimensions of reproductive anxiety, the highest score was for pregnancy ability (11.21 ± 2.62), which may be due to the fact that childbirth is an important component of building a harmonious family and maintaining marital relationships.Therefore, patients of childbearing age with gynecological malignancies are most concerned about their own pregnancy ability.Medical staff should pay attention to the psychological care of patients of childbearing age with gynecological malignant tumors, and provide effective measures to alleviate their reproductive anxiety.
The results of this study show that the total fear of recurrence score (20.98 ± 4.51) of patients of childbearing age with gynecological malignancies is at a moderate level, which is similar to the findings of Zhang et al. [22].Cancer recurrence fear refers to the psychological fear of patients with cancer towards the recurrence, metastasis, and progression of cancer in other or primary areas.It is mainly manifested as excessive tension, examination, and attention to changes in their own symptoms, and understanding symptoms such as chest tightness and pain as signs of worsening the condition [23].Female patients are generally more perceptive, and after learning of their own illness, their psychological burden increases, and they are more concerned about disease recurrence after treatment.At the same time, some gynecological malignancies have a higher degree of malignancy, making patients' fear of cancer recurrence more significant.Therefore,  [24], the family support score was at a moderate level (9.51 ± 1.68).Family support is an important component of social support, which is closely related to the mental health of patients [25].This study shows that family support for patients of childbearing age with gynecological malignancies is at moderate to upper levels, indicating a high level of support provided by the patient's family.This helps to improve the patient's psychological adaptability and promote mental health.Therefore, medical staff should inform and encourage patients' families, provide them with spiritual and material support, and improve their family support scores.

Analysis of the correlation between reproductive anxiety, fear of recurrence and family support
The results of this study show that the total score of reproductive anxiety and its various dimensions are positively correlated with the total score of recurrence fear, and negatively correlated with the total score of family support.Recurrence fear and family support are both influencing factors for reproductive anxiety in patients of childbearing age with gynecological malignancies, which is consistent with the results of Zhang et al. [26] and Wang et al. [27].Cancer, chemotherapy, surgery, and other related factors are inherently traumatic stress for patients, which can lead to negative psychological emotions such as anxiety and irritability, affect treatment compliance, and increase patients' concerns and fears about subsequent treatment [28].Among patients of childbearing age with gynecological malignancies, the higher the level of fear of cancer recurrence, the more worried they are that the disease will further affect their own health, pregnancy ability, and other reproductive functions, thereby increasing the level of reproductive anxiety.Family support plays an important role for

Analysis of influencing factors of reproductive anxiety
In addition to the fear of recurrence and family support, the number of children, educational level, treatment methods, and willingness to have children are all influencing factors for reproductive anxiety in patients of childbearing age with gynecological malignant tumors.This is consistent with the findings of Chen et al. [29] and Tan et al. [30].According to the analysis of the number of children and fertility desire, female patients who have not given birth and those who have fertility desire have a higher level of fertility anxiety, influenced by the traditional concept of "carrying on the family line" in China.Women who have not given birth and those who have fertility desire are under greater pressure to give birth.In addition, the policy of encouraging "two children" and "three children" can significantly increase the level of fertility anxiety of patients.

Conclusions
In summary, patients of childbearing age with gynecological malignant tumors have moderate levels of fertility concerns, fear of recurrence, and family support.Fertility concerns are positively correlated with fear of recurrence, and negatively correlated with family support.There are many influencing factors for fertility concerns, and more attention should be paid to patients who have no children, low education, surgery, chemotherapy, and desire to have children.We recommend that scientific interventions be developed for gynecological malignancies patients of childbearing age to reduce levels of fertility concerns.This study only selected four tertiary hospitals for investigation and research.The sample size and representativeness of the samples is limited, and there may be regional differences.In the future, the sample size can be expanded to further explore the factors related to reproductive anxiety in patients of childbearing age with gynecological malignancies.

Table 1
Fertility worries, fear of recurrence, and family support scores of gynecological patients of childbearing age with malignant tumors (n = 188)

Table 2
Correlation between fertility worry, recurrence fear and family support in patients of childbearing age with gynecological malignant tumors The results of this study show that the total family support score (9.57± 2.76) of patients of childbearing age with gynecological malignancies is at a moderate level.At present, there is no comparison of family support data for patients of childbearing age with gynecological malignant tumors in China.In the study of elderly patients with hypertension by Li et al.

Table 3
Univariate analysis of fertility worries in patients with gynecologic malignant tumors of childbearing age (n = 188)

Table 4
Assignment of independent variables in multiple linear regression analysis

Table 5
Results of multiple regression analysis of fertility worries in patients of childbearing age with gynecologic malignancies forms of diseases and fertility, providing effective psychological care, and carrying out reproductive protection and egg preservation.